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A 70-year-old man presented with right-sided transverses the greater palatine canal and supplies
epistaxis that had been unrelieved by direct pressure the anterior aspect of the septum.
for the past 90 minutes. His medical history was The internal carotid artery supplies the nose via
significant for hypertension (blood pressure was 180/ the terminal branches of the ophthalmic artery and the
100 mmHg on arrival), atrial fibrillation, and coronary anterior and posterior ethmoid arteries. These arteries
artery disease. His current medications are aspirin, branch from the ophthalmic artery within the orbit and
warfarin, enalapril, and metoprolol tartrate. On place- descend into the nasal cavity from above, supplying
ment of an anterior nasal pack on the right side, the the septum and lateral nasal walls. Of note, 2
patient began bleeding heavily from the left side. anastomotic areas within the nose often provide a
Epistaxis, or nose bleed, is a common problem, source of epistaxis. Woodruff area is located on the
affecting up to 60 million Americans each year. inferior aspect of the lateral nasal wall, posterior to the
Although most cases of epistaxis are relatively minor inferior turbinate. It is formed from the anastomoses
and manageable with conservative measures, some- of the sphenopalatine and pharyngeal arteries. The
times the malady can present as a life-threatening posterior location makes it a common source for
problem. The focus of this article is to review the severe, nontraumatic bleeds. Kiesselbach plexus is an
vascular anatomy of the nasal cavity as well as the anastomosis with branches from both the internal and
etiologies and management of epistaxis. external carotid artery systems. The anterior ethmoid,
greater palatine, sphenopalatine, and superior labial
VASCULAR ANATOMY arteries all form a plexus of vessels in the anteroin-
The nasal blood supply comes from both internal ferior nasal septum. Kiesselbach plexus is the source
and external carotid artery systems (Figure). The of the majority of nose bleeds.
external carotid provides arterial flow via the facial
and internal maxillary artery (IMA). The facial artery ETIOLOGIES
Epistaxis can be divided into local and systemic
forms the superior labial artery, which supplies the
etiologies. Furthermore, the most common causes of
septum and nasal alae. The IMA terminates into 5
epistaxis will change as the patient ages. One
branches: the sphenopalatine, pharyngeal, greater
constant among etiologies, though, is that epistaxis
palatine, infraorbital, and superior alveolar arteries. Of
increases in frequency during winter months. The
these 5 branches, only the sphenopalatine, pharyn-
decreased humidity along with decreased tempera-
geal, and greater palatine supply the nasal cavity. The
ture inhibits nasal humidification. The nasal mucosa is
sphenopalatine and its terminal branches supply the
subject to poor local wound healing and is therefore
septum and middle and inferior turbinate area. The
more susceptible to bleeding.1
pharyngeal artery also supplies the inferior aspect of
the lateral nasal wall, and the greater palatine
Local
The most common local causes of epistaxis are
trauma, anatomic deformities, inflammatory reactions,
Address correspondence to: and intranasal tumors.
Ronald G. Amedee, MD Epistaxis is most commonly encountered in the
Chairman, Department of Otolaryngology pediatric population secondary to digital trauma.2 Digital
Head and Neck Surgery irritation to Kiesselbach plexus is a very common source
Ochsner Clinic Foundation of anterior septal nose bleeds in children, especially
1514 Jefferson Highway during the winter months. The improper use of topical
New Orleans, LA 70121 nasal sprays is another source of epistaxis. Repeated
Tel: (504) 842-4080 trauma to the epithelium of the septal mucosa from
Fax: (504) 842-3979 sprays directed medially can cause intermittent epistax-
Email: ramedee@ochsner.org is. Proper counseling and instruction to direct the spray
away from the midline septum can alleviate this
Key Words: Epistaxis, nose bleeds problem. Trauma from a foreign body can elicit
Systemic
The most common systemic causes of epistaxis
are hypertension, aberrations in clotting ability,
inherited bleeding diatheses, and vascular/cardiovas-
cular diseases.
Although the mechanistic relationship of hyper-
tension and epistaxis is still being debated, the 2 are
undeniably associated. Hypertension is the most
common associated finding in cases of severe or
refractory epistaxis.3
The ability to form clots is essential to the
prevention and control of epistaxis. Both medica-
tion-induced clotting aberrations and liver dysfunc-
tion are common systemic factors influencing
epistaxis. Medications commonly associated with
epistaxis are aspirin, clopidogrel, nonsteroidal anti-
inflammatory drugs, and warfarin. Chronic alcohol
ingestion and renal dysfunction with associated
uremia uniquely cause platelet dysfunction. In the
setting of these specific diseases, liver function
tests and platelet counts are generally within
normal limits.
Blood supply of the nasal septum: (1) anterior ethmoidal The most common inherited bleeding disorders
artery, (2) posterior ethmoidal artery, (3) sphenopalatine associated with epistaxis are hemophilia A, hemo-
artery, (4) greater (anterior division) and lesser (posterior philia B, and von Willebrand disease. Hemophilia A
division) palatine arteries, (5) greater palatine artery, (6) and B are caused by deficiencies in factor VIII and
superior labial artery, and (7) Kiesselbach plexus. factor IX, respectively; both are integral components
in the coagulation cascade. von Willebrand disease is
epistaxis. Rhinorrhea may also be present secondary to caused by a qualitative or quantitative deficiency in
an associated foreign body reaction or infection. the von Willebrand factor, a glycoprotein essential to
Postsurgical epistaxis is a common phenomenon that the proper function of factor VIII. Inheritance of these
is usually amenable to conservative treatments. Lastly, disorders is sex-linked; only males are affected. A
the use of nasal cannula can cause epistaxis secondary preoperative work-up identifying these disorders can
to their local irritation as well as effects of nasal drying. potentially prevent life-threatening bleeding during
Septal deflections, bony spurs, and fractures are surgery. Desmopressin and cryoprecipitate can be
underlying anatomic deformities in the nose that can given prophylactically and therapeutically in these
predispose a patient to epistaxis. Any nasal obstruc- situations.
tion leads to a disruption of air flow. The resultant Vascular and cardiovascular diseases such as
turbulent flow anterior to these obstructions has a congestive heart failure, arteriosclerosis, and collagen
drying effect, increasing the opportunity for mucosal abnormalities can also be contributing factors to
disruption and epistaxis. Furthermore, severe deflec- epistaxis. A well-known association between hered-
tions/spurs can actually cause local trauma to the itary hemorrhagic telangiectasia and epistaxis has
lateral nasal wall mucosa. been determined.4 Hereditary hemorrhagic telangiec-
Any form of inflammatory or granulomatous disease tasia, or Osler-Rendu-Weber disease, has an autoso-
within the nasal cavity can cause bleeding. Common mally dominant inheritance pattern with incomplete
examples include bacterial sinusitis, allergic rhinitis, penetrance. Its presenting symptom is usually epi-
nasal polyposis, Wegner granulomatosis, tuberculosis, staxis secondary to telangiectasias of the nasal
and sarcoidosis. mucosa. Genetic mutations involving growth factor-
Finally, suspicion should arise for intranasal neo- beta result in fragile, injury-prone vessels with
plasms/vascular malformations involving recurrent nose deficiencies in elastic tissue and smooth muscle.
bleeds, especially unilateral ones, with no known cause.
Some examples of intranasal masses that can initially MANAGEMENT
present with epistaxis are inverted papillomas, angiofi- The management of epistaxis can be divided into
bromas, aneurysms, encephaloceles, hemangiomas, medical therapy, conservative therapy, surgical ther-
adenocarcinomas, and esthesioneuroblastomas. apy, and arterial embolization.